Download Policy For The Management Of Central Venous

Policies and Procedures for the Management
of Central Venous Catheters (CVC)
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1
Title:
Policies and Procedures for the Management of Central Venous
Catheters (CVC)
Policy Ref:
Organisation Wide
Directorate
Clinical Service
Sub Department
Area
✔
Controlled Document:
This document shall not be copied in part or whole
without the express permission of the author or the
author’s representative.
Review Date: August 2007
Author: CVC Working Group
Policy Application: NHS Grampian
Purpose:
To give all staff guidance in the management of Central Venous
Catheters
RESPONSIBILITIES FOR IMPLEMENTATION
Organisational
Clinical Group
Corporate
Departmental
Area
Policy Statement: The management of all aspects of Central Venous
Catheter care using evidence based practice.
Review:
This policy will be reviewed ever 2 years
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2
Policy for the Management of Central Venous Catheters (CVC)
Introduction
A Central Venous Catheter (CVC) provides venous access for patients
requiring short/long term therapies. To many patients the catheter is an
important lifeline, therefore it is imperative that the catheter is handled and
maintained correctly.
This policy has been developed by a multidisciplinary group to standardise the
management of CVC’s and to ensure that staff caring for the patient with
central venous catheters have access to guidelines and procedures to prevent
complications occurring.
The following evidence based procedures are available within this document.
Page
Supportive information on CVC’s
4 - 12
General Directions
13
Commencing IV Fluids via CVC
15
Disconnecting IV Fluids via CVC
17
Administration of Medicines via
CVC
19
Changing Closed Luer Lock
Device
21
Dressing the CVC
23
Adult - Taking Blood from CVC
using Vacutainer system
25
Paediatric – Taking Blood from
CVC
28
Removal of CVC
31
References
34
Bibliography
37
Appendix 1
Group Members
38
3
Venous Access
Definition
An intravascular catheter is defined as a ‘tubular’ device, single or multi lumen,
designed to be partially or totally inserted or implanted into the cardiovascular
system for diagnostic and/or therapeutic purposes’
Central venous access
Central catheters are used when access is required for

Infusion of high volumes of fluid.

Hydration or electrolyte maintenance.

Repeated administration of drugs such as chemotherapy or antibiotic
therapies.

Repeated transfusions of blood or blood products

Repeated collection of blood specimens.

Intravenous Nutrition.

Haemodialysis
or

When there is poor venous access.
Sites Available For Insertion

Subclavian

Internal/External Jugular

Femoral

Cephalic or Basilic
The most frequently used catheters are:

Non tunnelled CVC

Tunnelled catheters: i.e. Hickman, Broviac

Peripheral inserted central catheters (PICC)

Sub cutaneous ports
Table 1 lists the type of catheters available with their advantages and
disadvantages.
4
Table 1 Advantages and Disadvantages of Catheter Types
Midline catheter



Peripheral
Inserted Central
Catheter (PICC)




Non Tunnelled
CVC



Suitable for 1 - 12
weeks use
7.5cm-20cm in length
Longer than
peripheral cannula,
shorter than PICC
Central venous
catheter accessed via
a peripheral vein
20-40cm in length
Catheter tip
positioned in the
Superior Vena Cava
(SVC)
Suitable for up to 12
months use
Single or multiple
lumens
Used for short term
access
Inserted via internal
jugular/subclavian
Advantages

Ease of insertion and
removal

Avoids frequent
changes of cannula

Reduced risk of
thrombophlebitis







Ease of insertion and
removal
Fewer insertion
complications
Bedside access
Lower the incidence
of related
infection/thrombus
Can be inserted at the
bedside
Insertion procedure
quicker, suitable for
emergency situations
Several lumens, can
be used for
continuous access
and high flow
infusions
Disadvantages

Access to
peripheral veins
may be difficult

Occlusion
problems of
kinking/phlebitis

Cannot use to
infuse solutions
with high
osmolality/low pH

Smaller lumen/flow
problems

Inflammation at
the insertion site

Higher rate of
phlebitis than other
CVC’s

Problems with
kinking





Tunnelled CVC





Subcutaneous
Ports




Part of the catheter in
tunnel within the
subcutaneous tissue
Tip of the catheter in
the superior vena
cava
Cuffed, non-cuffed
Single or multi lumen
Last up to 3 years
depending on type of
catheter
Similar to tunnelled
catheters except
access via a
subcutaneous
reservoir
Use for prolonged
treatment
Single/double lumen
Accessed with a
Huber right angled
needle









5
Lower infection rate
Ease of dressing
application
Patient comfort, no
external sutures
Durability
Ideal for repetitive use
Don’t require skin
puncture for access

Patient acceptance,
intact body image
No exit site dressing,
allow patient to bathe
or swim
Require less
maintenance – less
flushing/no dressing
changes






Highest infection
rate
Requires external
sutures
Uncomfortable for
patients
Difficulty
maintaining
dressing at
catheter exit site
Requires to be
changed every 5
to 7 days
Experienced
operator required
to insert. Inserted
in theatre or
radiology dept.
Requires surgical
removal
External portion of
the catheter visible
Use of needle to
access port
Local skin
ulceration
Shorter life span
than tunnelled
CVC if accessed
regularly
Requires operative
placement
Midline catheter
PICC Line
Implanted Port
Hickman line
Triple Lumen
6
Single versus multi-lumen catheters
Multi lumen central catheters can be used for a combination of treatments such
as chemotherapy, or antibiotic therapy or nutrition. It has previously been
suggested that multi lumen catheters increase the risk of catheter-related
sepsis (Pemberton et al 1986) (McCarthy et al 1987). This point has now been
refuted by many authors who report that there is no statistical difference in
catheter-related sepsis between the use of single or triple lumen catheters.
(Johnston et al 1990), (Farkas et al 1992) (Ma Ty et al 1998) (Goetx et al
1998).
The choice of catheter for long term use is dependent on venous access
available, duration of therapy and, most importantly, patient preference. Table
2 lists the factors that should be taken into consideration when determining the
most suitable catheter for the patient.
As the availability of these intravascular devices increases, so must the health
professional's knowledge base improve. It is essential that health care
professionals receive regular educational updates and training sessions in
order to maintain standards.
Table 3 lists the appropriate use of lumens in multi-lumen catheters
Table 2 Factors Influencing Choice of Catheter
Location of venous access available
Gauge of catheter and vein diameter. The narrowest catheter in the largest vein will
provide better blood flow around catheter and reduce vein damage
Short or long term use
Catheter material: i.e. silicone or Polyurethane
Multi or single lumen catheter, Cuffed or uncuffed catheter
Implantable or external device
Method of catheter removal
Ease of sterile dressing applications
Patient preference/ body image,
Patients/carer’s ability to care for central catheter in the home environment
Table 3 Multi-lumen line - Lumen usage
Proximal
Blood Sampling
Medication
Blood Administration
Medial
Total Parenteral Nutrition (TPN)
Medication only if TPN not anticipated
Distal
CVP monitoring
Blood administration
High volume or viscous fluids
Colloids
Medication
th
4 Lumen
Medication
7
Catheter insertion
The central catheter should be inserted using an aseptic technique under the
supervision of an experienced clinician. Potential complications associated
with the insertion of the catheter include:
 Pneumothorax
 Venous air embolism
 Arterial puncture
 Catheter misplacement
 Cardiac Tamponade
 Cardiac arrhythmia’s
(Drewett 2000)
A catheter placed in an optimal position will reduce potential complications.
When inserting the catheter the clinician will consider the following points:
 The catheter tip should lie above the junction of the SVC and right atrium
 If a cuffed catheter is used, the cuff should be placed in the mid point of the
tunnel away from the exit site
 It is recommended that a Chest X-Ray should be performed to check the
position of the catheter before use.
Central Venous Catheter Care
Central venous catheter-related infections account for 90% of nosocomial
(hospital acquired) bloodstream infections. Despite the profuse availability of
evidence, there continues to be a significant diversity in practice of health care
professionals (Clemence et al 1995). It has been well documented that
experienced staff and educational programs (Parras et al 1994) can have a
significant impact on the rate of catheter related problems. For this reason it is
essential that all staff that are caring for a patient with a central venous
catheter have access to educational material and research based protocols
and procedures.
Hand Hygiene
The most common cause of the spread of nosocomial infection is via the
hands of health care workers because of their inability to effectively
decontaminate their hands. (Horton 1995). Therefore, the first crucial step in
the reduction of catheter related sepsis is knowledge of the principles of hand
hygiene and the effective use of disposable gloves.
Any procedure connected with an intravenous catheter requires the health
care worker to wash with an antibacterial handwash. The purpose of a
handwash is to remove dirt and to reduce the load of bacteria on the skin of
the hands. Washing with soap and water will remove the transient bacterial
flora, and washing with an antiseptic will reduce the resident bacteria on
hands. It should be noted however, that resident bacteria would not be totally
eliminated by handwashing. (Meers et al 1992) The are several types of
handwash available for use, each have different properties and advantages.
Choosing the appropriate agent will depend on several factors.
8
The use of any handwash solution will prove to be ineffective if staff do not
employ the correct handwashing technique. Various studies have concluded
that health care workers do not wash their hands effectively, leaving many
parts of the hands not exposed to soap, water or handwash. In practice the
most commonly missed areas are the fingertips, the thumb and the inside of
the fingers.
The use of an alcohol hand rub is known to be effective. It is a powerful
antiseptic that can be applied quickly to hands that are not soiled. It will rapidly
kill transient bacteria and a proportion of the resident bacteria.
The use of gloves
It is important that gloves are used in conjunction with hand hygiene and not
as a replacement. Many health care workers believe that gloves protect staff
and patients from cross contamination, but in reality this is not the case as
hands can become easily contaminated under gloves when they are
unwittingly punctured or when they are removed. The lack of evidence
regarding the benefits of using sterile gloves has resulted in many teams
developing procedures based on using an aseptic non-touch technique
(ANTT).
The care of the hub/the use of connection devices
Several studies have implicated contamination of the hub as the major source
of catheter related sepsis in catheters that remain in situ for more than two
weeks. Sitges Serra (1984) was concerned about the hub and recommended
that limited manipulations to the catheter should occur, as each junctional
break brings additional risk of infection.
Strict adherence to policies and effective hand hygiene techniques are
essential to minimise any risk
The use of closed luer lock connection devices (needle free) with a membrane
allows access to the catheter whilst maintaining a closed system. (Bionector,
Interlink, Smartsite).
Smartsite
Bionector
The perceived benefit of this system is:
 Reduction in catheter related sepsis (Segura 1996)
 Reduction in needle stick injuries
 Reduction in use of sterile equipment / reduce costs
9
 Reduction in nursing workload
Connection devices are now widely used in clinical practice. Some health
professionals are concerned about the potential risk of contamination. Several
studies have addressed this issue and conclude that there is no evidence that
their use is associated with increased risk of catheter related infection
(Seymour et al 2000), (Luebke at al 1998). When using connection devices the
greatest risk leading to contamination is an inability to disinfect the device
before puncture (Arduino et al 1997). The most effective method of disinfection
according to Brown et al (1997) is the use of a combination of chlorhexidine,
followed by 70% isopropyl swab.
Anecdotal evidence suggests that using the closed system is much less
cumbersome for nursing staff and patients to use and thus compliance with
procedures may be better. However, the use of the closed systems does not
diminish the need for careful catheter techniques, and the adherence of staff to
guidelines and educational programmes remains the most vital aspect in the
rate of catheter related sepsis (Ihrig et al 1997).
Recommendation – Bionector or Smartsite
Changing connection devices
Routine connection device changes should occur as per manufacturer’s
instructions. It may be necessary to change earlier if device is damaged, faulty,
or if blood products or lipid deposits are present after routine flushing of the
catheter.
Principles of catheter site care
The site forms an artificial break in the skin and with the catheter insitu is a
potential source of infection. An aseptic technique is therefore required when
cleaning the site and changing the dressing (Elliot 1993). It has been
suggested that the use of an aseptic technique by a specially trained person
has more effect on reducing the rate of catheter related infection than the type
of antiseptic or dressing used. (Nelson 1986)
There are several issues that require to be addressed when developing
guidelines for care of the catheter site. Firstly the most appropriate cleansing
solution, secondly the most appropriate dressing and thirdly how often the
dressing should be changed.
Cleansing Solutions
It is generally agreed that disinfection of the insertion site is essential. Various
antiseptic solutions are used during insertion and at dressing changes.
 Povidone iodine 10%
 Chlorhexidine 0.5%
 Chlorhexidine 2% (Maki 1991).
 0.9% Sodium chloride (Kennlyside 1992)
Chlorhexidine and alcohol based solutions have generally been shown to be
more effective. A study by Maki et al (1991) found chlorhexidine to be
significantly the most effective when used in the 2% aqueous solution. Mimoz
et al (1996) suggest that an alcohol based chlorhexidine solution was more
effective than povidone iodine, and Garland et al (1995) concluded that 0.5%
10
chlorhexidine in 70% alcohol was more efficacious than 10% povidone-iodine.
However Humar et al (2000) found that they was no difference between 0.5%
chlorhexidine and 10% povidone-iodine. There has also been interest in the
use of antiseptic impregnated catheter. A meta-analysis by Veenstra at al
(1999) concluded that central catheters impregnated with chlorhexidine and
silver sulfadiazine appear to be effective in reducing catheter- related infection.
Recommendation – Chlorhexidine 0.5% in 70%IMS
Dressings
The purpose of a dressing is

To prevent trauma to the wound and the cannulated vessel

To secure the catheter

To prevent extrinsic contamination
The optimal dressing for the site remains controversial. The type of dressings
frequently used includes sterile gauze dressing and transparent occlusive
dressing. Several studies have reported an increased rate of infection
associated with the use of transparent dressings. This is believed to be due to
an increase of moisture at the site (Hoffman et al 1992, Dickerson 1989).
However, other studies have found no statistical difference in rates of infection
between transparent or gauze dressing. (Madeo at al 1997), (Freiberger et al
1992), (Taylor at al 1996), (Little and Palmer 1998).
It has been suggested that transparent occlusive dressings are preferred by
the patient (Shivran at al 1991), are cost effective (Brandt et al 1996), and can
result in a reduction of nursing time. The need for any type of dressing has
also been studied. Lucas and Attard-Montalo (1996) concluded in their study
that the frequency of site infection was no greater when there was no dressing
applied. They concluded that the use of a dressing has no real benefit in
established long-term catheters.
 Gauze dressing - Mepore™, Primapore™
Limitations associated with the use of this dressing are the inability to visualise
the site and the need for frequent manipulation of the dressing if the site needs
to be checked. Their inability to provide a bacteria and water barrier allows for
the potential contamination from secretions or external moisture.
 Transparent/ occlusive dressing – IV 3000™, Tegaderm™
The advantage of a transparent dressing is the ability to secure the catheter, to
permit continuous inspection of the site, to adhere well to dry skin, and to
provide protection against external moisture sources. (Maki 1991).
Recommended dressing properties

Transparent – allows continuous visual inspection of the catheter and
catheter site

Self-adhesive – ensures greater stability, reducing the risk of trauma,
mechanical phlebitis and external contamination

Semi-permeable – protects from bacteria and liquid while allowing the site
to “breathe”

Sterile – prevents external contamination of the catheter site
11
Dressing Changes
There is no consensus on the issue regarding frequency of dressings but in
any protocol this needs to be established and should be weighed against the
exposure of the site to external micro-organisms. (Young et al 1988). While
daily dressings using an antiseptic cleansing solution will significantly reduce
skin colonisation (Roberts 1993), it is unclear whether colonisation is related to
sepsis and therefore there is a question about the necessity of this. Some
authors believe that the dressing is best left undisturbed for as long as
possible to reduce the possibility of contamination (Dougerty 1992). Although
transparent dressing can remain in-situ for 7 days, it may need changed earlier
if there is drainage from the site or the dressing becomes non-occlusive
(Brandt et al 1996).
Recommendation - Opsite IV 3000 for subclavian lines or
Tegaderm for Jugular lines
Changed weekly or sooner if soiled with blood or
exudate or if not adhering to the skin.
12
General Directions
Pre Procedure
The following are a set of general instructions to be observed prior to
commencing any procedure.
Procedure
Rationale
1. Wash and dry hands.
1. To minimise the risk of cross
infection.
2. Clean trolley/tray/flat surface as
per NHS Grampian Cleaning,
Disinfection and Sterilisation
Policy.
2. To minimise the risk of infection
3. Prepare and assemble all
equipment required for procedure.
3. Procedure can be completed
without interruption.
4. Reassure and explain the
procedure to the patient/relative in
terms that can be understood and
gain verbal consent.
4. To have a patient/relative who is
knowledgeable of the procedure
and a healthcare worker who has
been given the authority to
proceed.
5. Ensure privacy during the
procedure, do not expose the
patient unnecessarily and avoid
draughts.
5. To avoid unnecessary
embarrassment to the patient and
minimise airborne contamination.
6. Provide adequate lighting.
6. To enable clear observation.
7. Wear clean disposable white
apron.
7. To lessen the possibility of uniform
contamination.
Post Procedure
The following are a set of general instructions to be observed when a
procedure has been completed.
Procedure
Rationale
1. Wash and dry hands.
1. To minimise the risk of cross
infection.
2. Leave the patient comfortable and
the area clean and tidy.
2. To ensure patients comfort.
13
3. Clean equipment according to NHS 3. To minimise the risk of cross
Grampian Cleaning, Disinfection
infection.
and Sterilisation Policy.
4. Return all opened Sterile Services
Department (SSD) items for
reprocessing, protecting sharp
instruments.
4. For cleaning and reprocessing.
5. Dispose of clinical waste as per
NHS Grampian Waste Disposal
Policy.
5. To comply with the Environmental
Protection Act and Duty Of Care
Legislation.
6. Document the procedure in the
appropriate records.
6. Accurate records of the patients
care journey are available.
14
Procedure for Commencing Infusions via a Central Venous
Catheter (CVC)
The use of 3 way taps are not recommended on central venous catheters due
to the inability to clean effectively and the increased risk of introducing
infection from not having a closed system. Closed luer lock systems are
recommended e.g. Bionector®, Smartsite® or Interlink®.
Total Parenteral Nutrition (TPN)/ Intravenous Nutrition (IVN) as a highly
specialised feed has the ingredients to readily sustain bacterial growth
and therefore adherence to strict aseptic technique is paramount.
The administration set for IV fluids should be changed every 24 hours as per
NHS Grampian policy unless a local policy has been discussed and agreed
with Infection Control.
Any local policy should be attached to this document.
Requirements
1.
2.
3.
4.
5.
6.
Fluid (Additive Medicine) Prescription and recording sheet
Prescribed IV fluid
Appropriate IV administration set and infusion device as required
Alcohol impregnated swab
Chlorhexidine hand wash solution e.g. Spirigel® with pump dispenser
Alcohol hand gel e.g. Spirigel® with pump dispenser
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
2. Two nurses check infusion fluid and
patient identity with prescription
chart as per NHS Grampian policy.
2. To ensure correct IV fluids are
given to the correct patient at the
correct time.
3. Wash hands with Chlorhexidine
handwash
3. To minimise the risk of cross
infection
4. Open new IV administration set and
leave in packet.
4. To minimise contamination.
5. Close clamp on CVC, and on used
administration set. Stop infusion
device if in use.
5. Prevents air from entering the
system.
6. Disconnect from closed luer lock
connector.
7. Decontaminate hands with alcohol
hand gel.
7. To minimise the risk of cross
infection.
15
8. Prime giving set placing coil of set
onto open packet. Use correct
procedure for gravity sets and
infusion devices as per
manufacturer's instruction.
9. Open alcohol impregnated swab
and drop swab onto packet of
administration set .
10. Decontaminate hands with alcohol
hand gel.
10. To minimise the risk of cross
infection.
11. Holding CVC near the end, wipe
around the end of the connector
with alcohol impregnated swab
allow to dry fully (minimum of 30
seconds).
11. To facilitate optimum disinfection
of the connector.
12. Pick up end of administration set
and connect firmly and securely to
the connector.
13. Ensure CVC is secured safely with
the end away from wounds and
stoma’s.
15. To minimise the risk of catheter
infection.
14. Open clamp on CVC line, set
infusion device (volume and rate)
and commence or open clamp on
gravity set to commence infusion.
15. Follow Post Procedure General
Directions.
17. See Post Procedure General
Directions.
Note: It is important that users of infusion devices are proficient in their use.
16
Procedure for Disconnecting Infusions via a Central Venous
Catheter (CVC)
The use of 3 way taps is not recommended on central venous catheters due to
the inability to clean effectively and the increased risk of introducing infection
from not having a closed system. Closed luer lock systems are recommended
e.g. Bionector®, Smartsite® or Interlink®.
Requirements
1.
2.
3.
4.
10 ml syringe(s)
Green needle(s)/Filter needle
Alcohol impregnated swab x 2
10mls of Sodium Chloride 0.9% w/v and/or 5mls of Heparinised Saline
(Hepsal)
5. Chlorehexidine hand wash solution e.g. Hibiscrub® with pump dispenser
6. Alcohol hand gel e.g. Spirigel® with pump dispenser
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
2. Wash hands with Chlorhexidine
handwash.
2. To minimise the risk of cross
infection.
3. Using a non touch technique
draw up Sodium Chloride 0.9% w/v
and/or Heparinised Saline.
3. Sodium Chloride 0.9% w/v is
adequate to flush the line if it is
being used frequently i.e. every
day. If not Sodium Chloride 0.9%
w/v followed by Heparinised Saline
is recommended. (Local policy may
apply).
For lines designated for TPN
administration both should be
used.
4. Close clamp on CVC lumen and
administration set. Switch off pump.
Disconnect used administration set
from closed luer lock connector
5. Decontaminate hands with Alcohol
hand gel.
5. To minimise the risk of cross
infection.
17
6. Holding the lumen near the end
wipe the end of the closed luer lock
with the alcohol impregnated swab
allow to dry fully (minimum of 30
seconds).
6. To facilitate optimum disinfection
of the connector.
7. Attach the syringe containing the
sodium chloride 0.9%w/v to the
connector, open the clamp and
using the push, pause technique
instil the sodium chloride 0.9%w/v.
7. This causes more turbulence in the
lumen and is more effective in
flushing the line and maintaining
patency.
8. Close clamp when flush is
complete, keeping pressure on
the plunger of the syringe, remove
syringe and discard.
8. Positive pressure can reduce reflux
of the blood into the catheter.
9. Repeat steps 7 & 8 with
Heparinised saline if required.
10. Check CVC clamp is closed and
clean end of closed luer lock
connector with a new alcohol
impregnated swab.
11. Ensure line is secure.
12. Follow Post Procedure General
Directions
12. See Post Procedure General
Directions.
18
Procedure for Administration of Medicines via a Central
Venous Catheter (CVC)
Administration of medicines via central lines should always be via a closed luer
lock connector i.e. Bionector®, Smartsite® or Interlink®.
The use of 3 way taps are not recommended on central venous catheters due
to the inability to clean effectively and the increased risk of introducing
infection from not having a closed system.
Non-sterile gloves should be worn for the protection of the healthcare
worker when reconstituting and administering any medicines especially
antibiotics.
Requirements
1.
2.
3.
4.
5.
6.
7.
8.
9.
Prescription chart, with patients name, unit number, date of birth
Prescribed medicine(s)
Medicine Additive label(s)
Ampoule Sodium Chloride 0.9% w/v at least 10mls but will depend on the
number of medications to be given
Dead ender/IV Plug for the end of each syringe
Alcohol impregnated swab x 2
Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser
Alcohol hand gel e.g. Spirigel® with pump dispenser
Non sterile gloves
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure general
Directions.
2. Wash hands with Chlorhexidine
hand wash
2. To minimise the risk of cross
infection.
3. Reconstitute medicines as per Trust
policy and as per manufacturers
advice.
3. To ensure safe reconstitution and
safe delivery to the patient.
4. Draw up Sodium Chloride 0.9% w/v
5. Attach sterile dead enders and label
each syringe as it is prepared.
5. To minimise contamination of the
syringe tips and identify medicine in
syringe.
6. Explanation and patient
identification checks as
recommended in NHS Grampian
Policy.
6. To ensure the correct medicine
is given to the correct patient at
the correct time.
7. Decontaminate hands with Alcohol
hand gel.
7. To minimise the risk of cross
infection.
19
8. Holding CVC near the end wipe
around the end of the closed luer
lock connector with an alcohol
impregnated swab. Allow 30
seconds to dry.
8. To facilitate optimum disinfection of
the connector.
9. Attach syringe containing Sodium
Chloride 0.9% w/v to closed luer
lock connector, open clamp and
flush catheter with 5mls of Sodium
Chloride using the “push, pause”
technique. (1ml at a time)
Volume of flush may need to be
reduced in paediatrics.
9. This causes more turbulence in
the line and is more effective in
flushing the line and maintaining
patency.
10. Close clamp keeping pressure on
syringe plunger. Remove syringe
from closed luer lock connector and
re-cover tip of syringe
10. Positive pressure can reduce the
reflux of blood into the
catheter tip.
11. Attach medicine syringe, open
clamp and administer medicine as
per Trust Policy and as
recommended by manufacturer.
11. Medicines must be
administered slowly to prevent
speedshock.
12. Close clamp and remove syringe.
13. Reattach syringe containing Sodium 13. Sodium Chloride 0.9% w/v is
Chloride 0.9% w/v to closed luer
thought to be adequate when the
lock connector, open clamp and
CVC is being used at least on a
instil 5 mls Sodium Chloride 0.9%
daily basis (excluding TPN).
w/v into the CVC using push pause
technique, close clamp keeping
pressure on plunger of syringe as
before and then remove.
Volume of flush may need to be
reduced in paediatrics.
14. Repeat steps 11 – 13 as necessary.
15. Check clamp is closed and clean
end of closed luer lock connector
with a new alcohol impregnated
swab.
16. Document administration of
medicines in drug recording chart.
17. Follow Post Procedure General
Directions.
17. See Post Procedure General
Directions.
20
Procedure for Changing Closed Luer Lock Device
The use of closed luer lock connection devices (needle free) with a membrane
allow access to the catheter whilst maintaining a closed system. Closed luer
lock systems are recommended e.g. Bionector®, Smartsite® or Interlink®.
These devices should be changed as per manufacture’s instructions. Usually
once a week. It may be necessary to change earlier if device is damaged,
faulty or if blood products or lipid deposits are present after routine flushing of
the catheter.
Requirements
1.
2.
3.
4.
5.
6.
7.
8.
9.
Dressing pack
New closed luer lock connector
10ml syringe
5mls of Sodium Chloride 0.9%w/v
Green needle/Filter needle
Sterile procedure gloves.
Alcohol impregnated swab
Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser
Alcohol hand gel e.g. Spirigel® with pump dispenser
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
2. Wash hands with Chlorhexidine
handwash.
2. To minimise the risk of cross
infection.
3. Open pack and place other
equipment onto sterile field. Place
opened ampoule of Sodium
Chloride 0.9% w/v on trolley next to
sterile sheet.
4. Place sterile drape under existing
connector.
5. Decontaminate hands with Alcohol
hand gel and put on sterile gloves.
5. To minimise the risk of cross
infection.
6. Using a non touch technique draw
up Sodium Chloride 0.9% w/v.
6. To prevent contamination of gloves.
21
7. Attach syringe to new connector
and flush with Sodium Chloride
0.9% w/v.
7. To prevent air entering the system.
8. Ensure catheter is clamped. If the
catheter has no clamp eg a PICC,
kink back a portion of the catheter.
8. To prevent possible entry of air.
9. Unscrew old connector and discard.
Clean catheter hub with alcohol
impregnated swab allow to dry fully
(minimum of 30 seconds).
9. To facilitate optimum disinfection of
the catheter hub.
10. Attach new connector securely.
(Finger tight only - do not
overtighten).
10.Overtighten can cause cracking of
the catheter hub.
11. Discard gloves.
12. Follow Post Procedure General
Directions.
12. See Post Procedure General
Directions.
22
Procedure for Central Venous Catheters Dressings (CVC)
The dressing that is in place after insertion should be left but observed closely
especially in the first 24 hours. Dressings should be changed if soiled with
blood or exudate or if not adhering to the skin. This should be weekly or more
often if required.
The insertion site should be checked daily for swelling, inflammation, pain or
discharge or signs that the line may have moved e.g. pulled.
Requirements
1.
2.
3.
4.
5.
6.
7.
Sterile dressing pack
Sterile procedure gloves
Non sterile gloves
Sterile dressing ( e.g. Tegaderm, Opsite 3000)
Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser
Alcohol hand gel e.g. Spirigel® with pump dispenser
Chlorhexidine 0.5% in 70 % IMS. (check patient sensitivity)
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
8. Wash hands with Chlorhexidine
handwash.
2. To minimise the risk of cross
infection.
9. Put on disposable apron.
10. Open sterile dressing pack onto
dressing trolley.
11. Open gloves onto sterile field.
6. Pour Chlorhexidine 0.5% in 70%
IMS into one of the containers in the
tray of the dressing pack.
7. Put on non sterile gloves
10. To protect the healthcare worker
from body fluid contamination.
8. Carefully remove old dressing from
the catheter site and discard.
8. Some CVC’s are not sutured in
place so care must be taken to
prevent moving or dislodging the
catheter.
23
9. Remove and discard non sterile
gloves.
10. Decontaminate hands with
Alcohol hand gel. Put on sterile
gloves.
10. To minimise the risk of cross
infection.
11. Using strict aseptic technique ,
11. Strict asepsis is required to prevent
clean the area around the catheter
infection being introduced into a
with the Chlorhexidine solution 0.5%
major blood vessel from cross
in 70% IMS. Gently clean the skin
contamination or by introducing
using a circular movement from the
resident skin flora.
catheter outwards. Clean an area
larger than was covered by the old
dressing. Allow the skin to dry.
12. Remove gloves and discard.
13. Apply the dressing onto the skin,
one end first, gently press down
ensuring no air bubbles are trapped
underneath. Ensure line is secure.
14. Follow Post Procedure General
Directions.
14. See Post Procedure General
Directions.
24
Adults - Procedure for Taking Blood from Central Venous
Catheters (CVC) Using Vacutainer System
Blood samples should not be taken routinely from a CVC except in
specialist areas where a local policy applies.
If line sepsis is suspected blood cultures will be required to be taken
from the CVC.
It is recommended that blood specimens are taken from a CVC with the
vacutainer system and that a closed luer lock connector is in situ (e.g.
Bionector, Interlink or Smartsite).
The use of vacutainer system may not be appropriate in paediatrics.
Requirements
1. Non sterile gloves
2. Blood tubes and /or blood culture bottles for required tests (x1 spare 10ml
tube)
3. Alcohol impregnated swab
4. Syringes x2 (10 ml)
5. Vacutainer needle holder
6. Blue Vacutainer (with needle and connector end)
7. Interlink bare cannula x 3 (when Interlink product in use)
8. 5mls Heparinised Saline
9. 10mls of Sodium Chloride 0.9% w/v
10. Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser
11. Request form with patient details
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
2. Assemble relevant blood specimen
tubes as requested on the request
form and all relevant equipment.
3. Wash hands using Chlorhexidine
handwash
3. To minimise the risk of cross
infection.
4. Draw up 10mls of Sodium Chloride
0.9% w/v (attach bare cannula if
using Interlink).
5. Draw up 5mls Heparinised Saline
into 10ml syringe (attach bare
cannula if using Interlink).
5. Larger syringe is recommended
by manufacturer. This minimises
pressure in the line and blood
vessel.
25
6. Assemble vacutainer device
(attach bare cannula if using
Interlink).
6. This device minimises the risk of
needlestick injuries.
7. If CVC in use device close clamp on
CVC and switch off infusion.
8. Put on non-sterile gloves.
8. To protect the healthcare worker
from body fluid contamination.
9. Holding CVC near the end wipe
around the end of the closed luer
lock connector with alcohol
impregnated swab, allow to dry fully
(minimum of 30 seconds).
9. To facilitate optimum disinfection of
the connector.
10. Ensure clamp on CVC lumen is
closed. Insert needle-less end of
blue vacutainer into the closed luer
lock connector.
11. Attach spare blood tube, open
clamp on lumen, and withdraw
10mls of blood, close clamp, and
discard initial blood sample.
*See note in relation to blood
cultures
11. To ensure blood specimen is not
contaminated.
12. Take the other blood samples
12. This ensures that plain tubes are
closing the clamp between each
not contaminated by additives from
tube. (start with plain tubes and then
other tubes.
additive tubes inverting gently)
13. Close CVC clamp and remove
vacutainer device/syringe and
discard in sharps container.
14. Attach syringe containing Sodium
Chloride 0.9% w/v to closed luer
lock connector, open CVC clamp,
and flush using push pause
technique. Close clamp and
remove syringe.
14. This causes more turbulence in the
line and is more effective in
flushing the line and maintaining
patency.
15. Attach syringe containing
Heparinised Saline, open clamp
and flush, close clamp and remove
syringe.
15. Prevents line from becoming
occluded.
26
16. Ensure blood tubes are correctly
identified with patient details
(addressogram labels are not
acceptable). Forward specimens to
laboratory with completed request
form.
16. Ensure patient safety.
17. Follow Post Procedure General
Directions.
17. See Post Procedure General
Directions.
*For blood cultures, it is important that potential infection in the CVC
device is not discarded, so therefore point 11. should be ignored and no
blood should be discarded.
Trouble shooting

Unable to get blood - If the line is flushing but you are unable to withdraw
blood, it may be due to a positional problem.
- Ask the patient to change position e.g. sit forward or back.
- Ask the patient to lift their arm up and down
- Ask the patient to cough
- Ask the patient to breath deeply
Sometimes the above will be enough to move the line. If none of the above
work do not persist, simply flush the line and leave it. Inform medical staff of
the inability to obtain blood.

-
Unable to flush or get blood
Check that where the clamp has been closed the lumen is not indented,
massaging gently to prevent pinching can open the lumen.
You should never feel anything other than slight resistance, if you do the
line requires assessment.
Do not under any circumstances try to force fluid into the line, the extra
pressure may be caused by a clot which has formed at the end of the lumen.
27
Paediatric - Procedure for Taking Blood from Central Venous
Catheters (CVC)
If line sepsis is suspected blood cultures will be required to be taken
from the CVC.
The use of vacutainer system may not be appropriate in paediatrics.
Requirements
1.
2.
3.
4.
5.
6.
7.
8.
9.
Non sterile gloves
Blood tubes and /or blood culture bottles for required tests
Alcohol impregnated swabs
Syringes
Needles are required if taking blood cultures
5mls Heparinised Saline
10mls of Sodium Chloride 0.9% w/v
Chlorhexidine handwash solution e.g. Hibiscrub® with pump dispenser
Request form with patient details
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
2. Assemble relevant blood specimen
tubes as requested on the request
form and all relevant equipment.
3. Wash hands using Chlorhexidine
handwash solution.
3. To minimise the risk of cross
infection.
4. Draw up 10mls of Sodium Chloride
0.9% w/v.
5. Draw up 5mls Heparinised Saline
into 10ml syringe
5. Larger syringe is recommended
by manufacturer. This minimises
pressure in the line and blood
vessel.
6. If CVC in use close clamp on CVC
and switch off infusion device.
7. Put on non-sterile gloves.
7. To protect the healthcare worker
from body fluid contamination
28
8. Holding CVC near the end wipe
around the end of the closed luer
lock connector with alcohol
impregnated swab, allow to dry fully
(minimum of 30 seconds).
8. To facilitate optimum disinfection of
the connector.
9. Insert syringe into closed luer lock
system. Unclamp CVC and gently
withdraw 2mls blood. Clamp CVC
remove syringe and discard
sample.
*See note in relation to blood
cultures.
10. Insert new syringe into closed luer
lock system, open clamp on CVC
and gently remove sufficient blood
for samples required. Clamp CVC
and remove syringe.
10. To ensure blood specimen is not
contaminated.
11. Attach syringe containing Sodium
Chloride 0.9% w/v to closed luer
lock connector, open CVC clamp,
and flush using push pause
technique. Close clamp and
remove syringe.
11. This causes more turbulence in the
line and is more effective in
flushing the line and maintaining
patency.
12. Attach syringe containing
Heparinised Saline, open clamp
and flush, close clamp and remove
syringe.
12. Prevents line from becoming
occluded.
13. Fill blood tubes with appropriate
quantity of blood.
If taking blood cultures
(a) Wipe blood culture bottle top with
alcohol swab and allow to dry
(b) attach needle to syringe
(c) insert into rubber bung of culture
bottle allow vacuum to draw blood
into bottle.
(d) Discard needle and syringe
immediately into sharps container.
14. Ensure blood tubes are correctly
identified with patient details
(addressogram labels are not
acceptable). Forward specimens to
laboratory with completed request
form.
29
14. Ensure patient safety.
15. Follow Post Procedure General
Directions.
15. See Post Procedure General
Directions.
*For blood cultures, it is important that potential infection in the CVC
device is not discarded, so therefore point 9 should be ignored and no
blood should be discarded.
Trouble shooting

Unable to get blood - If the line is flushing but you are unable to withdraw
blood, it may be due to a positional problem.
- Ask the patient to change position e.g. sit forward or back.
- Ask the patient to lift their arm up and down
- Ask the patient to cough
- Ask the patient to breath deeply
Sometimes the above will be enough to move the line. If none of the above
work do not persist, simply flush the line and leave it. Inform medical staff of
inability to obtain blood.

-
Unable to flush or get blood
Check that where the clamp has been closed the lumen is not indented,
massaging gently to prevent pinching can open the lumen.
You should never feel anything other than slight resistance, if you do the
line requires assessment.
Do not under any circumstances try to force fluid into the line, the extra
pressure may be caused by a clot which has formed at the end of the lumen.
30
Procedure for Removal of a Central Venous Catheter (CVC).



This is an aseptic technique performed by a doctor or qualified nurse
trained in the procedure.
The valsalva manoeuvre is performed by requesting the patient to take a
breath in and attempt to breath out with their mouth and nose closed. Some
patients may find it useful to pinch their nose closed whilst performing this
manoeuvre. (See note)
Please note; if the CVC has a dacron cuff (e.g. a Hickman type line) it will
need to be dissected out in the operating theatre, unless staff have been
specifically trained in this procedure.
Requirements
1. Dressing pack
2. Sterile scissors (if tip of CVC required for microbiology)
3. Universal container (if required for CVC tip)
4. Stitch cutter and forceps (if required)
5. Non sterile gloves x 1pr
6. Sterile procedure gloves x 1pr
7. Adhesive airtight dressing
8. Chlorhexidine 0.5% in 70% IMS
9. Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser
10. Alcohol hand gel e.g. Spirigel® with pump dispenser
Procedure
Rationale
1. Follow Pre Procedure General
Directions.
1. See Pre Procedure General
Directions.
2. Explain procedure to patient,
including the valsalva manoeuvre
and gain consent to remove central
line.
2. To decrease anxiety and increase
compliance to ensure safe removal
of the central line and prevent
complications.
3. Wash hands with Chlorhexidine
hand wash solution.
3. To minimise the risk of cross
infection.
4. Position patient lying flat in bed with 4. This raises the central venous
one pillow under shoulders and
pressure above atmospheric
head.
pressure and may prevent air being
aspirated into the venous system.
5. Switch off any IV infusions running
through CVC.
31
6. Decontaminate hands with Alcohol
hand gel.
6. To minimise the risk of cross
infection.
7. Open dressing pack and then open
all other requirements onto sterile
field. Pour a small amount of
Chlorhexidine 0.5 in 70% IMS into
one of the containers in the tray of
the dressing pack.
7. To maintain asepsis.
8. Open gloves and place onto
another clean surface.
8. To minimise contamination of open
dressing pack.
9. Put on non-sterile gloves.
9. To protect the healthcare worker
from body fluid contamination
10. Remove old dressing carefully from
CVC site.
11.Remove non sterile gloves and
discard.
12.Decontaminate hands with Alcohol
hand gel and apply sterile gloves.
12. To minimise the risk of cross
infection.
13 Clean exit site with cleansing
solution.
13. To minimise the risk of cross
infection.
14. Remove sutures if present.
15. Ask the patient to perform the
valsalva manoeuvre (*or to take a
breath and hold it.)
15. This manoeuvre raises
intrathoracic pressure and will
minimise the risk of air embolism.
16. Hold the CVC near the exit site and
while the patient is doing the
valsalva manoeuvre (see note)
remove CVC. If resistance is felt
stop immediately and seek medical
advice.
16. Holding the catheter near the exit
site ensures stability along the
length of the catheter. This
reduces the risk of CVC fracture.
17. As the catheter is withdrawn, apply
gentle pressure around the exit site
using a gauze swab.
17. To prevent haemorrhage and
bruising.
18. If the tip of the CVC is required for
microbiology, it should be placed
into a universal container held by
an assistant, who should then cut
the catheter with the sterile
scissors.
18. CVC tips should only be sent to
microbiology if there are clear
clinical indications or on medical
instruction.
32
19. Continue to apply firm pressure
until bleeding has stopped.
19. To prevent haemorrhage and
bruising.
20. Remove gloves and discard
21. Apply a small airtight dressing to
the exit site which should remain in
situ for 48 hours.
21. Fibrin tracts can form along the
length of the CVC , which can
provide a portal for air entry after
removal of the CVC.
An airtight dressing will help to
prevent this and give the tract time
to heal.
22. Check the catheter is intact. The
tip should be smooth, not ragged.
22. To ensure no catheter fracture. If
suspected inform medical staff
immediately
23. Reposition the patient for comfort
and observe the site closely for
30mins.
23. To observe for signs of re-bleeding
and swelling.
24. Follow Post Procedure General
Directions
24. See Post Procedure General
Directions.
25. Document procedure in nursing
notes.
Note
“A Valsalva manoeuvre (forced expiration against a closed glottis) in the
supine position may be the most effective technique. A practical way of
achieving this without protracted explanation is to ask the patient to blow into a
20ml syringe with enough force to push back the plunger. They will not be able
to achieve this, but they will perform the valsalva manoeuvre during the
attempt. “
Advanced Life Support Course Provider manual 4th Edition (Revised) 2004
Resuscitation Council (UK)
33
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3. Resuscitation Council UK Advanced Life Support Provider Manual 4th
Edition (Revised) Jan 2004 102
4. Nice Institute for Clinical Excellence - Technology Appraisal Guidance – No
49. Sept 2002 Guidance on the use of ultrasound locating devices for
placing central venous catheters
5. Infection Control Nurses Association Guidelines for preventing intravascular
catheter-related infection June 2001
6. Royal College of Nursing Standards for infusion therapy October 2003
37
Appendix 1
Group Members
Dorothy Barber
Nutrition Nurse Specialist
Justine Collie
ANCHOR Development Nurse
Vanessa Dunbar
S/N Theatres
Lynne Flett
S/N Ward 32
Claire Fraser
S/N Ward 35 HDU
Mary Glasgow
Practice Educator GI & Vascular
Melaine Hendry
S/N Neonatal Unit AMH
Sue Danby (nee Miles) Sister Ward 4 RACH
Anne Smith
Senior Nurse Infection Control
Acknowledgements To
Helen Corrigan
Sister Infection Unit
Claire Jamieson
Practice Educator
Tanya Learmonth Lead Nurse Chemotherapy Team
Elaine Nicol
Practice Educator Renal
Helen Ogg
Practice Educator General Surgery
Linda Still
Sister Ward 35 HDU
The nurses from the Scottish Managed Clinical Network for Home Parenteral
Nutrition
38